Spectrum of thrombotic complications and their outcomes in Chinese children with primary nephrotic syndrome

Case report: cerebral venous sinus thrombosis and pulmonary embolism as the initial presentation in a child with asymptomatic primary nephrotic syndrome

Background

Cerebral venous sinus thrombosis (CVST) is rare, but potentially life-threatening. The clinical course definitely become more unpredictable and fatal in patients complicated by pulmonary embolism (PE). Nephrotic syndrome (NS) is an uncommon etiology of CVST. Concurrence of CVST and PE at the initial onset of NS is extremely unusual and rarely reported. Considering that edema might be absent in NS individuals, thromboembolic events probably become unrecognized, thereby causing a missed or delayed diagnosis and poor outcome. Herein, we described an extraordinary case of an adolescent boy presenting with both CVST and PE initially just within 5 days of disease onset, who was ultimately diagnosed with asymptomatic NS, aiming to emphasize a high index of suspicion of these diseases in patients with conditions of hypercoagulability.

Case presentation

A 13-year-old male child presented acutely with dizziness, fever and dyspnea, with signs of shock but undetected edema. Initial laboratory investigations revealed hypoalbuminemia, typical images of pneumonia, and normal radiographic findings on non-enhanced computed tomography of head. Despite evidence of hypoalbuminemia and neurological symptoms, the child was still misdiagnosed as pneumonia. His dyspnea and period of headache deteriorated even if hemodynamic stability and undetected fever after initial therapy. The delayed urinalysis and 24-h urine examination both showed massive proteinuria. A computed tomography angiography of chest along with cranial magnetic resonance imaging/magnetic resonance venography were subsequently performed, consistent with the imaging features of PE and CVST, respectively. The diagnosis of asymptomatic primary NS complicated by PE and CVST was ultimately confirmed. The patient received corticosteroids and antithrombotic therapy with satisfactory results.

Conclusion

A persistent clinical suspicion of CVST should be borne in mind in patients with a sudden, new or worsening headache, specifically among those with prothrombotic conditions. NS should always be considered in the differential diagnosis of risk factors for CVST, even in absence of edema. Since CVST and PE can be present simultaneously at extraordinary early-onset of NS, early radiological diagnosis is clinically substantial to proper management and satisfactory long-term outcomes.

Incidence of thromboembolism in children with primary nephrotic syndrome: a systematic review and metaanalysis

OBJECTIVE

To estimate the incidence of thromboembolism in children with primary nephrotic syndrome with Meta-analysis.

METHODS

Relevant studies published from January 1, 1980 to December 31, 2021 were retrieved from Pubmed, Web of science, Cochrane library, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database(VIP) and Wangfang Database. Quality evaluation of the literatures included was conducted according to Agency for Healthcare Research and Quality(AHRQ) assessment tool, followed by data extraction and Meta-analysis with software RevMan 5.3.

RESULTS

A total of seven studies involving 3675 subjects were included. The overall prevalence was 4.9% with 95% CI of 2.83 to 7.05.However, a significant heterogeneity (P < 0.001) was observed with I² = 89%. The prevalence of venous thromboembolism was 3.3% with 95% CI of 1.7 to 4.9. The prevalence of arterial thromboembolism was 0.5% with 95% CI of 0.2 to 1.4.

CONCLUSION

Children with nephrotic syndrome are prone to thromboembolism, and it may lead to disability or death, therefore prevention measures is critical to decreasing the prevalence of thromboembolism.

Disease-Associated Systemic Complications in Childhood Nephrotic Syndrome: A Systematic Review

Introduction

Nephrotic syndrome (NS) is one of the most common childhood kidney diseases. During the active phase, the disease pathogenesis affects various biological functions linked to loss of proteins negatively, which can result in systemic complications. Complications of childhood NS are divided into two categories: disease-associated complications and drug-associated complications. However, complications in pediatric patients with NS, especially disease-associated complications are still limited. Although reported in the literature, information is not comprehensive and needs to be updated. This study aimed to systematically assess systemic complications in children with NS, especially disease-associated complications, to better understand how they impact outcomes.

Methods

We conducted a systematic search of several databases: BioMed Central Pediatrics, PubMed, Google Scholar, the National Library of Medicine, Cochrane Library, CINAHL/EBSCO, British Medical Journal, Science Direct, Scopus, and Elsevier’s ClinicalKey. We followed the PRISMA guidelines to plan, conduct, and report this review. We used the Joanna Briggs Institute’s critical appraisal tools for assuring the quality of the journal articles that were chosen.

Results

Eleven articles concerning complications in childhood NS were analyzed. Systemic disease-associated complications in covered were cardiovascular complications, infections, thyroid-hormone complication, kidney complications, and oral health complications.

Conclusion

NS is marked by heavy proteinuria, hypoalbuminemia, edema, and hyperlipidemia, which can result in systemic disease-associated complications. Cardiovascular complications, infections, thyroid-hormone complications, kidney complications, and oral health complications are the main systemic complications in childhood NS. It is essential that health-care providers prevent these complications for proper maintenance of patients’ health.

Risk factors and new diagnostic index for deep venous thrombosis of lower extremities in elderly patients with traumatic femoral neck fracture

Purpose

To determine the incidence and risk factors of deep vein thrombosis (DVT) of lower extremities at admission in elderly Chinese patients with femoral neck fracture, and to establish and evaluate a new DVT predictor based on these risk factors.

Methods

Patients who were hospitalized from January 2018 to December 2020 at three independent centers were reviewed. According to the results of lower extremities vascular ultrasound at admission, they were divided into DVT group and non-DVT group. Single and multivariate logistic regression analysis were applied to identify independent risk factors for DVT occurrence, and then a prediction formula for DVT based on the risk factors was developed. The new predictive index of DVT was calculated by the formula. Receiver operating characteristic (ROC) curve analysis was used to determine the diagnostic value of different factors and the new predictive index.

Results

There were 203 elder patients were included in the final analysis after application of the exclusion criteria. Thirty seven patients (18.2%) were diagnosed as DVT by ultrasound, including 33 patients (89.2%) of peripheral type, 1 patient (2.7%) of central type and 3 patients (8.1%) of mixed type.Multivariate logistic regression analysis showed that four factors including injured side, hemoglobin, fibrinogen, d-dimer were the independent risk factors for the incidence of DVT. On this basis, a new formula for DVT predictive factor was constructed: New predictive index = 0.895 * injured side (right = 1, left = 0) + 0.899 * hemoglobin (<109.5 g/L = 1, > 109.5 g/L = 0) + 1.19 * fibrinogen (>4.24 g/L = 1, < 4.24 g/L = 0) + 1.221* d-dimer (>2.4 mg/L = 1, < 2.4 mg/L = 0). The AUC value of this new developed index was 0.735.

Conclusions

This work showed that the incidence of DVT in elderly patients with femoral neck fracture in China was high at admission. New DVT predictive value can be used as an effective diagnosis strategy for evaluation of thrombosis at admission.

Thromboembolic complications in children with primary nephrotic syndrome: A Tunisian series

INTRODUCTION

Nephrotic syndrome is a common pathology in children. Despite its good prognosis, it can become complicated and threaten the patient's vital and functional prognosis. Thromboembolic complications are rare but serious.

AIM

To study the main thromboembolic events and their outcome during primary nephrotic syndrome in children.

METHODS

It was a retrospective study of the records of children followed for primary nephrotic syndrome who presented one or more thromboembolic events.

RESULTS

Twenty thromboembolic events in 19 children were identified (15 boys and 4 girls). The average age was 5.13±3.4 years at the time of NS diagnosis. The location of the thrombosis was venous in 14 cases. Cerebral venous thrombosis was noted in seven cases, pulmonary thromboembolism in five cases. We noted deep venous thrombosis of lower limbs in three cases, occlusive mesenteric ischemia in two cases, vein portal thrombosis in one case, renal vein thrombosis in one case, and thrombosis of a peripheral artery in one case.

CONCLUSION

Venous and arterial thrombotic complications can occur in children with nephrotic syndrome. Clinical features may be subtle; therefore, neuroimaging and angiographic techniques are essential for diagnosis.